Patient Name
*
First Name
Last Name
Application Date
*
MM
DD
YYYY
Manitoba Health #
*
Email
*
Phone (Home)
*
(###)
###
####
Phone (Work)
*
(###)
###
####
Phone (Cell)
*
(###)
###
####
Address
*
Please include Home + Postal Including Postal Code
Message
*
Date of last Dental Visit
MM
DD
YYYY
Have you ever had any of the following? Please check those that apply.
*
Are you taking any Medications? If yes, please list.
*
Have you ever had any complication following dental treatment? If yes, please explain.
*
Are you under the care of a physician? If yes, please let us know who.
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Have you been admitted to a hospital or needed Emergency care in the last 2 years?
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Do you have any health issues that need further clarification?
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To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
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Who can we thank for referring you to our Practice?
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The following is for:
*
The Patient's Spouse
The Person responsible for payment
Responsible Party Name
*
First Name
Last Name
Please Select Option that best describes
I identify my gender as:
*
I am
*
Birth Date of Responsible Party
*
MM
DD
YYYY
Best Phone # for Responsible Party
*
(###)
###
####
Address of Responsible Party
*
The Following is for:
*
The Patient
Person Responsible for Payment
Occupation
*
Employer's Name
*
Address of Employment
*
Name of Insured
*
First Name
Last Name
Is insured a patient?
*
Insured's Birth Date
*
MM
DD
YYYY
ID #
*
Group #
*
Insured's Address
*
Insured Employer Name
*
Insured Employer Address
*
Patient's relationship to insured
*
Insurance Plan Name + Address
*
Name of Insured
*
First Name
Last Name
Is Insured a Patient?
*
Insured's Birth date
*
MM
DD
YYYY
ID #
*
Group #
*
Insured's Address
*
Insured Employer Name
*
Insured Employer Address
*
Patient's Relationship to Insured?
*
Insured Plan Name + Address
*
Please be informed that due to the invasive nature of dental procedures, the following complications are possible during routine restorative, surgical (simple or complicated), or preventative services; SWELLING, BRUISING, BLEEDING,PAIN, INFECTION, ROOT SENSITIVITY, TRANSIENT OR PERMANENT PARAESTHESIA (NUMBNESS OF LIP OR TOUNGUE). This list does not cover all possible complications.
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As with any dental or medical procedure, no guarantee of treatment results can be made or implied. All effort will be made to complete your dental treatment with care and quality service which includes extensive sterilization and disinfection procedures.
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